How to select patients for natural orifice surgery
(Editor's note: This month's issue includes the second part of a two-part series on natural orifice surgery. In this month's issue, we explore patient selection, physician skills, and tools in development. Last month, we gave you an overview of the current status of the surgery.)
Selection of patients for natural orifice surgery does not differ greatly from selection of patients for any minimally invasive surgery but, because the procedure is still in the research stage, there are a few precautions surgeons should take, suggests Marc Bessler, MD, director of laparoscopic surgery and director of Obesity Center, New York Presbyterian Hospital at Columbia University, New York City.
"I perform the procedure through the vagina, so I will not offer the procedure to a patient who has a previous pelvic or upper abdominal surgery," he says. As more information is gathered on the procedure during clinical trials, the need for this precaution and the effect of scarring from previous surgeries may be determined not to affect the outcome, he explains. Also, Bessler won't perform this procedure if the gallbladder is inflamed or if the patient is not in good general health.
Natural orifice surgery also may provide an option for patients for whom abdominal or laparoscopic surgery represents increased risks, says Christopher J. Gostout, MD, FASGE, professor of medicine and director of endoscopic research and development at the Mayo Clinic in Rochester, MN.
"[Natural orifice surgery] may have a more specific role in obese individuals for whom laparoscopic and open surgery is less desirable," Gostout says. The ability to avoid incisions and the reduce need for anesthesia will be beneficial to this group of patients, he says.
Flexible endoscopes and laparoscopic tools that can be used through the scopes for cutting, suturing, and extracting organs do exist, but instruments are in development that are specific to natural orifice procedures and that can increase the range of procedures performed, Gostout says.
"New instruments are needed and are being developed," he says. It is a major area of awareness within the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) Joint Committee and the working groups that meet annually during the Natural Orifice Transluminal Endoscopic Surgery (NOTES) conference, Gostout says. NOSCAR is a working group of expert laparoscopic surgeons from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and a group of expert interventional endoscopists representing the American Society for Gastrointestinal Endoscopy (ASGE). (Editor's note: For information on research and current developments related to the surgery, go to www.noscar.org. The web site includes white papers, resources, conference information, and updates on the procedure.)
Physicians and device manufacturers are working collaboratively to develop specific flexible tools that are compatible with a flexible endoscope, Gostout points out. Natural orifice surgical devices will have to duplicate the functions of current laparoscopic tools, he says.
Tools specifically for natural orifice surgery will have to be longer and miniaturized, Gostout explains.
"The basic functions will include tissue grasping, cutting, and suturing, or its equivalent," he says. "Additionally, specialized ports and overtubes in varying lengths will be needed to maintain access to the abdominal cavity and prevent soiling or contamination."
(Editor's note: This month's issue includes the second part of a two-part series on natural orifice surgery. In this month's issue, we explore patient selection, physician skills, and tools in development. Last month, we gave you an overview of the current status of the surgery.)You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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